Variance Request Form – Fill Out and Use This PDF

VARIANCE REQUEST FORM

BOARD OF PHARMACY RULE 6800.9900 VARIANCES

Subpart 1. Right to request variance. A person subject to the rules of the Board of Pharmacy may request that the board grant a variance from any rule of the Board of Pharmacy.

Subp. 2. Submission and contents of request. A request for a variance must be submitted to the board in writing. Each request must contain the following information:

A.the specific rule for which the variance is requested;

B.the reason for the request;

C.the alternative measures that will be taken if a variance is granted;

D.the length of time for which a variance is requested; and

E.any other relevant information necessary to properly evaluate the request for the variance.

Subp. 3. Decision on variance. The board shall grant a variance if it determines that:

A.the variance will not adversely affect directly or indirectly, the health, safety, or well-being of the public;

B.the alternative measures to be taken, if any, are equivalent or superior to those prescribed in the part for which the variance is requested; and

C.compliance with the part for which the variance is requested would impose an undue burden upon the applicant.

The board shall deny, revoke, or refuse to renew a variance if the board determines that item A, B, or C has not been met.

Subp. 4. Notification. The board shall notify the applicant in writing within 60 days of the board's decision. If a variance is granted, the notification shall specify the period of time for which the variance will be effective and the alternative measures or conditions, if any, to be met by the applicant.

Subp. 5. Renewal. Any request for the renewal of a variance shall be submitted in writing prior to the expiration date of the existing waiver. Renewal requests shall contain the information specified in subpart 2. A variance shall be renewed by the board if the applicant continues to satisfy the criteria contained in subpart 3 and demonstrates compliance with the alternative measures or conditions imposed at the time the original variance was granted.

Subp. 6. Research projects. Pharmacists desiring to participate in research or studies not presently allowed by or addressed by rules of the board may apply for approval of the projects through waivers or variances in accordance with subparts 1 to 4.

PERSON SUBJECT TO THE RULES OF THE BOARD OF PHARMACY REQUESTING THIS VARIANCE

NAME: ____________________________________________________________________ LICENSE #:___________________________

LIST THE SPECIFIC RULE(S) FOR WHICH THE VARIANCE IS REQUESTED: 6800:___________________6800:_________________

LIST THE NAME AND LICENSE NUMBER OF THE SITE(S) AFFECTED

NAME___________________________________LICENSE #__________NAME____________________________LICENSE#__________

ADDRESS ___________________________________________________ADDRESS ___________________________________________

STATE THE REASON FOR THIS REQUEST: (It is required that the variance request result in equivalent or improved public safety and in equivalent or improved patient outcomes) _______________________________________________________________________________

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POLICIES AND PROCEDURES DEVELOPED TO IMPLEMENT THE VARIANCE REQUEST: (Please attach if more space is needed)

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QUALITY ASSURANCE / QUALITY IMPROVEMENT: PLEASE DESCRIBE THE METHODOLOGY AND STANDARDS FOR MONITORING OUTCOMES. (Please attach if more space is needed) ________________________________________________________

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FOR WHAT LENGTH OF TIME IS THIS VARIANCE REQUESTED?
___ 3 MONTHS	___ 6 MONTHS	___ 12 MONTHS	___ OTHER, PLEASE LIST _________________

OTHER RELEVANT INFORMATION THE BOARD OF PHARMACY SHOULD CONSIDER ALONG WITH THIS REQUEST:

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SIGNATURE: ______________________________________________________________________ DATE:________________________